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Detection & Diagnosis of Atrial Fibrillation in Primary Care Dr Eric CAJEAT Springfield Primary Care Centre NHS Lambeth CVD Lead AF…. Most common cardiac arrhythmia Major risk factor of stroke: Annual incidence 5-6 times greater in patients with AF Responsible for about 45% of all embolic strokes Ischaemic strokes associated with AF often fatal Terrible consequences of AF-related stroke: From a “silent” condition to a disabling condition High morbidity /mortality (X2/other causes of stroke) Higher risk of recurrence than for other causes of stroke Cost of care X1.5 Stroke risk is preventable: Warfarin reduces risk of stroke: 68% in primary prevention 62% in secondary prevention Under-used: 53% of males / 40% of females with AF were receiving oral anticoagulants (in 2003) 20% to 40% people with AF who are eligible are not receiving anticoagulation! NNT prevent 1 stroke 37 4,500 strokes/year 3,000 deaths/year through improved services / optimal therapy could be prevented DeWilde S, Carey IM, Emmas C et al. (2006) Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 92: 1064-1070. Ruigomez A, Johansson S, Wallander MA et al. (2002) Incidence of chronic atrial fibrillation in general practice and its treatment pattern. Journal of Clinical Epidemiology 55: 358-363. Batty GM, Grant RL, Aggarwal R et al. (2003) Using prescribing indicators to measure the quality of prescribing to elderly medical in-patients. Age and Ageing 32: 292-298. But… AF is often asymptomatic 69% in euro heart survey …. unless, screened or diagnosed at time of complication / hospital admission. Prevalence: an aged-related condition: 1 to 2 % of total UK population 5% over 65 year-old 10% over 80 year-old True prevalence certainly much higher, >2% of total population plus with an ageing population: new “epidemic” Nieuwlaat, R., Capuci, A et al. (2005), Atrial fibrillation management: a prospective survey in ESC members countries, European Heart Journal, 26, pp. 2422-2434. The prevalence problem.... DeWilde et al.: Trend 1993 > 2003 of diagnosed AF Data from 131 general practices (about 1 million reg. pats. annually) Estimated 2003 prevalence of active/ever diagnosed AF: 1.31% and 1.49% respectively in men, 1.15% and 1.29% respectively in women aged >85 years:13.2% in men and 11% in women. 2007/2008 QOF data national prevalence of diagnosed AF is 1.30% DeWilde S, Carey IM, Emmas C et al. (2006) Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart 92: 1064-1070. .... are we doing well? 2006/07 QOF data – raw (unadjusted) figures. PCT Prevalence Low CI High CI London 0.8 0.79 0.8 Bromley 1.36 1.32 1.4 Greenwich 0.8 0.76 0.83 Lambeth 0.53 0.51 0.56 Lewisham 0.56 0.54 0.59 Southwark 0.56 0.54 0.59 NHS information centre, Clinical and Health Outcomes Knowledge Base , available at: www.nchod.nhs.uk/NCHOD/Compendium.nsf/2217490fcc66bd94802573a30020fcd6/49b9f8b9217bbc90802576870040faed!Ope nDocument Lambeth Data Combined Model (Oct 08-Sept 09) Based on registered population / QOF AF registers Unadjusted prevalence: Total prevalence: 0.56% 66-75 year-old: 3.37% Over 76 year-old: 8.92% Large variations between practices: Total prevalence: 0.15 to 1.25% 66-75 year-old: 0 to 9.3% Over 76 year-old:3.75 to 20.58% Detection of AF? 1- Symptoms: Breathlessness / dyspnoea: De novo Deterioration with pre-existing condition: e.g. HF, COPD…. (loss of Atrial “kick”) Palpitations Chest discomfort Syncope / dizziness Stroke / TIA Heart Failure 2- Screening: Opportunistic Systematic Screening: some evidences… Opportunistic Pulse check in Durham1: 1,883 patients over 65 (practice population of 11,423) 1,569 pulses checked, 207 irregular pulses out of which 130 patients no known AF 99 had an ECG 39 newly diagnosed cases of AF (detection rate of 2.48%) Prevalence: - from 1.32% to 1.82% - In over 65 > 10.9% NHS stroke improvement programme (2009), Atrial fibrillation – detection and optimal therapy in primary care, available at: http://www.library.nhs.uk/qualityandproductivity/ [accessed 19/01/2009] Opportunistic screening in North-East Essex: 37 practices signed-up LES 43,210 patients screened in 6 weeks at flu clinics Outcomes: - Cost: - 3,154 patients with irregular pulse (9.2%); 189 patients AF (0.55%); 342 patients other arrhythmias 77 patients CHADS2 stratified as being at risk for stroke and started on Warfarin Overall cost: £68,402 Screening costs: £2 per patient Cost per diagnosis: £362 Savings: - 5 strokes prevented during the next year at £44,000 each (based on a 5% incidence of stroke in patients with AF and 50% reduction with Warfarin) - Annual cost saving (recurrent): £220,000 Return on investment: 322% NHS stroke improvement programme (2009), Atrial fibrillation – detection and optimal therapy in primary care, available at: http://www.library.nhs.uk/qualityandproductivity/ [accessed 19/01/2009] 1 Best opportunistic screening opportunities: Flu clinic Medication review Elderly population Chronic illness monitoring: important co-morbidity Diabetes: 20% of AF have diabetes! Hypertension IHD HF: up to 30-40% of patients with HF Valvular Heart Disease (LA distension, early in MR/MS but late in Ao disease) COPD CKD Other associated co-morbidities: Thyroid dysfunction Sleep apnoea AND new NHS health check programme ! -Every 5 years -All patients aged between 40 and 74 years - exclude patients with known hypertension, ischemic heart disease, stroke, diabetes and chronic kidney disease -universal risk assessment and management programme Pulse palpation…. Quick, simple and reliable High sensitivity, 95% (unlikely to miss an individual with AF) Moderate specificity, 75% (could misclassify an individual who does not have AF as having AF) Low Positive Predictive Value, 8-23% Taking pulse for a period of 20 seconds increases specificity (98%) but reduces sensitivity (50%) Dewar, R.I., Lip, G.Y.H et al. (2007), Identification, diagnosis and assessment of atrial fibrillation, Heart, 93, pp.25-28. Cooke, G., Doust, J, & Sanders, S. (2006), is pulse palpation helpful in detecting atrial fibrillation? A systematic review, The journal of family practice, 55 (2), pp. 130-134. The tricky ECG ! Irregular pulse should ALWAYS raise the possibility of AF but ECG is essential to establish the diagnostic But highly dependant on interpretation! Mant et Al. (2007)1 SAFE study, 49 practices, 2595 patients/ECGs, compared 49 GPs – 49 nurses – ECG interpretative software, consultants cardiologist as gold standard, Mant, J., Fitzmaurice, D.A. et al. (2007) Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial, BMJ, 335(7616). 1 GPs: - - PNs: - - Similar sensitivity 77% (CI 67-85%) Lower specificity (85%, CI 83-87%) Software: - detected 79/99 cases of AF (sensitivity 80%, 95% CI 71-87%) misinterpreted 114/1355 cases of SR (specificity 92%, 95% CI 9093%) Low PPV: 40.9% , so more likely to be wrong… Similar sensitivity 83% > so still missed cases!!! • No rhythm diagnosis in 4.3% (109) • Missed 12% (26) of AF or 17% (36) if inclusion of no rhythm Higher specificity 99% > more accurate. GPs + Software: 92% sensitivity & 91% specificity Conclusion: “many PCP cannot accurately detect AF on an ECG and interpretative software is not sufficient to circumvent this problem” o AF criteria: Irregularly irregular rhythm P wave: - - No distinct P waves, wavy baseline Sometime or in some leads: “fine” or “f” waves <1mm, “coarse” or “F” waves > 1mm If seen atrial rate >350ppm PR interval: not measurable QRS: - - irregularly irregular RR interval (refractory period of AV node) Normal shape unless intra-ventricular conduction problem or added ectopics Variable ventricular response: Slow <60 Fast 100 Geiter, H.B. Jr. (2007), E-Z ECG rhythm interpretation, Philadelphia: F.A. Davis company. Huszar, R.J. (2002), Basic dysrhythmias, Third edition, St Louis : Mosby. Rowlands, D.J. (1993), Electrocardiography pocket hand book, Dordrecht : Kluwer academic publishers & Servier laboratories ECG differential diagnosis... Mainly supraventricular arrhythmias Atrial tachycardia Atrial flutter Atrial ectopics : e.g. Multifocal Atrial Tachycardia: In doubt contact our local cardiologists! Next steps.... 1- Look for evidence of: Symptoms of IHD Duration and pattern of AF: ?paroxysmal HF Structural HD: e.g. heart murmur Thyroid disease Other risk factors for stroke: hypertension, diabetes, smoking status 2- Blood tests: U&E FBC TFT LFTs Fasting lipids and glucose INR 3- Further investigations Chest x-ray: if suspicion of abnormality based on clinical history and examination Transthoracique echocardiography: When important for long-term management e.g. younger patients High risk or suspicion of underlying structural heart disease Refinement of clinical risk stratification for antithrombotic therapy is needed Rhythm control strategy including cardioversion is considered The National Collaborating Centre for Chronic Conditions (2006), Atrial fibrillation: National clinical guideline for management in primary and secondary care [internet], The National Collaborative Centre for Chronic Conditions : Royal College of Physicians of London, available at http://guidance.nice.org.uk/CG36/Guidance/pdf/English [accessed 7/09/2007] Heath, R. & Lip, G.Y.H. (2009), 10 steps before you refer for atrial fibrillation, British Journal of Cardiology, 15(6), pp. 302-305. 3- Initiate treatment: Risk stratify for risk of stroke Anticoagulation therapy: - Initiate rate control therapy: - Ideally on day one of diagnosis or as early as possible after diagnosis Estimate risk of stroke > e.g. CHAD2 score Estimate risk of bleeding BB first line If CI, rate-limiting Ca+ antagonist Especially if AF is not well tolerated ? Cardiology referral Hobbs, F.D.R. (2003), Stroke prevention in atrial fibrillation, British Journal of Cardiology, 10(5), available at www.medscape.com/viewarticle/462550_print [accessed 02/01/2010] http://www.improvement.nhs.uk/stroke/N ationalProjects/StrokePreventioninPrimary CareAF/tabid/76/Default.aspx Conclusion: TAKE YOUR PATIENTS’ PULSE OPPORTUNISTICALLY Think effective stroke prevention & do a CHAD2 score 150,00 stokes per year in the UK 410 per day, 17 per hour, 10 within the next 4 hours…. 8 would have been known to be at high risk of stoke 6 should have been on Warfarin 3 will go home, 5 will end up in residential care, 2 will die….. www.stroke.org.uk Fay., M (2009), Models for screening for atrial fibrillation, Heart Rhythm Congress, available at www.heatrythmcongress.com [accessed 16/01/2010]